Helicobacter Pylori: The Case Study

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Table of Contents

Patient Information
Past Medical History
Objective Assessment
Differential Diagnoses
Plan
Reflection
References

Patient Information

The patient initials are A. B. 59 years of age, male and of the African American race.

Chief Complaint

“I have had rib and abdominal pain.”

History of Presenting Illness

The 59-year-old African American male presented with complaints of ribs and abdominal pain, in H. Pylori and is alert and oriented for the last four days. The Helicobacter Pylori (H.Pylori) is characterized by constant pain in the abdomen. Patient was noted with hypertension, GERD, epigastric pain, malaise, and fatigue. Treatments provided included education and encouragement on the importance of hydration and rest for fatigue improvement and for malaise.

Current Medications

Amoxicillin 500mg 1 tablet by mouth twice daily for 10 days (H. Pylori).
Metronidazole 500mg 1 tablet by mouth twice daily for 14 days (H. Pylori).
Administer Hep B, Tdap, and Shingrix vaccine(H.Pylori)
Hydrocholorthiazide at 25 mg once daily (high blood pressure).
Clarythromycin 50 mg PO twice daily for 10 days (gastritis)

Allergies

The patient reports no drug or food allergies.

Past Medical History

The patient has a history of hypertension, epigastric pain and GERD. He is currently undergoing medications to reverse these conditions. His previous hospitalization was due to elevated blood pressure and GERD. However, he has no history of surgery. The patient’s immunization history is not up to date with the Hep B, Tdap, and Shingrix vaccines indicated for treatment. As a child, records indicate that the patient received Tetenus toxoid vaccine.

Social History

The patient is a married man who lives with his wife and three children, who are all alive and healthy. The patient agrees to having been a chain cigarette smoker and enjoys occasional alcohol consumption. He is a retired professional driver who sometimes used cell phone while driving. He also reports tying his car seat belt whenever he drives.

Family History

The patient reports a history of hypertension, type 2 diabetes, and cancerous cases in his immediate relatives.

Review of Systems

General:

Fatigue
Body malaise
Normal appetite
Slight weight loss.

HEENT:

Reports having no headache
Reports light headedness sometimes
Reports no vision problems
No hearing loss or ringing in the ears
No mouth problems

SKIN:

No skin rashes or itching
No instances of dry skin

CARDIOVASCULAR:

Mild chest pain or chest discomfort
Occasional blood pressure monitoring

RESPIRATORY:

No difficulties in breathing.
Reports having no cough.

GASTROINTESTINAL:

Reports having constant upper gastrointestinal pain.
Slight weight loss
Reports changes in appetite

GENITOURINARY:

Reports no pain while urinating
No burning on urination

NEUROLOGICAL:

Reports slight dizziness
Reports occasional numbness in the lower extremities

MUSCULOSKELETAL:

Reports no muscle pain
Reports no back pain and joint pain

HEMATOLOGIC:

No anemia
Denies experiencing episodes of bleeding or bruising

LYMPHATICS:

Denies History of spleen surgery

PSYCHIATRIC

Denies history of Depression

ENDOCRINOLOGIC:

Reports history of night sweating
Denies presence of polyuria

ALLERGIES:

No history of allergies

Objective Assessment

The general assessment shows that the patient is well nourished and well groomed. The vital signs during examination are BP 142/84, pulse rate of 85, the oral temperature of 98.1 (Fahreinheights), and pain at 6/10.

Chest: rises and falls with respirations. On auscultation of the heart, s1 and s2 sound heard with no extra heart sounds. Lung sounds are clear.

Abdomen: pain on the ribs at 6/10.

Differential Diagnoses

Helicobacter Pylori (H.Pylori) is always linked to Gastric biopsies as the present infection without the actual determination of the causative organism (El-Zimaity et al., 2018). Acute gastritis: pain in the abdominal area can result from a sudden inflammation of the mucosa, in what is acute gastritis (El-Zimaity et al., 2018).

Gastric cancer: Abdominal pain can result from the effects of stomach cancer, which has been reported to be elevated by the presence of Gastroesophageal reflux disease (Thrift & El-Serag, 2020).

Stress-induced gastritis: This is the inflammation of the stomach, which results from the interruptions of the pH of the stomach. This change thus affects the normal digestive processes following the extra release of stomach acid in stressful situations (Megha et al., 2020). This can result into severe abdominal pain.

My primary diagnosis is seasonal acute gastritis. This is due to symptoms of the reported H. pylori infection and the reported pain in the upper abdomen as is observed from the patient’s history.

Plan

Whereas the treatment modalities vary depending with the causative agents, pharmacological interventions have for decades been considered. Some of the medications include antibiotics, antacids, histamine (H2) blockers, such as Cimetidine and Proton pump inhibitors such as Omeprazole (Azer & Akhondi, 2020). Further, it has been reported that the treatment of H. Pylori related gastritis should consider a three modal approach of Clarithromycin, Omeprazole and amoxicillin for between two to three weeks (Azer & Akhondi, 2020).

Besides, the treatment of acute gastritis involves the use of medication as well as dietary and behavior change modals in the daily activities of an individual. However, medication interventions are considered only if the other alternatives fail to work (Azer & Akhondi, 2020).

Reflection

I concur with the current treatment of the condition because it seeks to address the abdominal pain as the patients’ chief complaint. According to Azer and Akhondi (2020), medications seeking to decrease the stomachs acidity are generally effective in addressing stress induced gastritis. The most common medications include proton pump-inhibitors, H2 blockers, and antacids, which normalize gastric pH and rate of stomach ulceration. I learnt that several contributing factors leading to disease development and approaches to treatment should assume a wide scope of information through proper history taking. Patient education on prevention behaviors should be provided in order to avoid the risk factors associated with gastritis.

References

Azer S. A, Akhondi, H. (2020). Gastritis. StatPearls Publishing. Web.

El-Zimaity, H., Choi, W. T., Lauwers, G. Y., & Riddell, R. (2018). The differential diagnosis of Helicobacter pylori negative gastritis.Virchows Archiv, 473(5), 533-550. Web.

Megha, R., Farooq, U., & Lopez, P. P. (2020). Stress-induced gastritis. StatPearls Publishing. Web.

Thrift, A. P., & El-Serag, H. B. (2020). Burden of gastric cancer.Clinical Gastroenterology and Hepatology, 18(3), 534-542. Web.